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Dr. Khosla:
Hi, my name is Seema Khosla and I'm a Sleep Medicine Physician practicing in Fargo, North Dakota, and I'd like to share with you some obstructive sleep apnea screening tools.

So, as my colleagues have previously delineated, obstructive sleep is a really important disorder to diagnose and to treat. As primary care clinicians, you are well positioned to effectively screen for sleep disordered breathing, and this doesn't have to take a lot of time. These are questionnaires that can live in your waiting room.

So, the first one is called the STOP-Bang. S is for snoring, T is tired, O is observed events like apneas, P is pressure - do they have high blood pressure? And then, we look at some patient characteristics. BMI greater than 35, A is age greater than 50, N is neck circumference, so 16 inches in women, 17 in men, and G is gender, so you get 1 point if you're a male. So, you add them all up 1 point each, and if you're greater than 3, you may wish to consider further evaluation. If you really want to hone in, though, on the ones that are at highest risk, you may want to change this to looking at those who score greater than 5.

Another questionnaire is one that you may already be utilizing. This one is called the Epworth Sleepiness Scale. It’s not specific for obstructive sleep apnea, but it does look to see how sleepy your patients are. It asks a series of questions and ask them how likely would you be to doze off in a given situation? Usually boring, like as a passenger in a car or in a theater, 0is I would not doze off, 3 is I would be very likely to dose off. The highest you can score is 24, and we think that 10 or greater signifies pathological hypersomnolence.

So even though the Epworth isn't specific for obstructive sleep apnea, we do have the Berlin Questionnaire, which is. So, there are various categories and if your patient scores positive in 2 or more, so, greater than 1, they are felt to be at high risk for obstructive sleep apnea. So, out of all of these, if you have to pick one, STOP Bang probably is the one to choose. This one had the highest sensitivity among sleep clinic patients.

And so, some caveats. These screening questionnaires are not meant to exclude obstructive sleep apnea, and they haven't been validated in all patient populations. So, if we think about our patients of Asian descent, or our female patients, including those who are perimenopausal or pregnant, they are often overlooked. So, that clinical symptomatology is really important. Please know that identifying, diagnosing, and treating these patients can really make a positive impact in their lives.

So, I'd like to share a clinical vignette with you. We have a 35-year-old G5P1 who you see at 33 weeks. So, she started snoring beginning her second trimester. At that time, her BMI was 31, neck circumference 37 inches. Her STOP-Bang was 3, her Epworth was 6, and she actually underwent a home sleep apnea test at that time that was negative. So, now you see her in clinic, her BMI is 36, her neck circumference is a little bit bigger, her blood pressure is up a little bit. Now, her STOP-Bang is 4 and her Epworth is 11. And so, you do a home sleep apnea test, and she has severe obstructive sleep apnea. She has an apnea hypopnea index of 69. And so just to refresh you, 5 to 15 is mild, 15 to 30 is moderate, and above 30 is severe. And this is physiologically really important for her. She desaturates down to 63%.

So, a lot of the advice we give our pregnant patients is, whatever is ailing you is going to get better when the baby comes, right? Restless leg syndrome, acid reflux. Not true for sleep apnea, though. It doesn't always resolve with delivery, and so it's really important to keep these patients on your radar.

We worry about this because our pregnant patients with untreated sleep apnea have a higher rate of eclampsia and pre-eclampsia, and they have a higher Cesarean section rate. They have a lot of really bad outcomes even after delivery. So, remember, pregnancy is a window into future health. So, these are patients that you really do want to continue to follow as you see them year over year, and you want to continue to ask them about their sleep and their sleep apnea symptomatology.

So, what happens if you have a patient that doesn't meet criteria with these screening questionnaires, but you still think they have sleep apnea? Please order the test. These questionnaires are good, but they're limited, especially in populations where the screening test hasn't been validated. They're not meant to replace your clinical judgment. If you think they have sleep apnea, please order the test. So, I've included some references for you where you can download these questionnaires. I've included a very pretty copy of the STOP-Bang, as well as a cheat sheet for how to interpret it, and I'd be happy to take any questions you may have.

I hope that you've enjoyed this presentation.

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